Intermediate cardiovascular risk in an Australian man — case discussion

Presentation

Practice case (not a real patient). A 58-year-old non-Indigenous man in Australia sees his general practitioner for a health check. He has no known cardiovascular disease and no diabetes. He does not smoke. His father had a myocardial infarction at 50.^[6] His office BP is 138/86 mmHg and his LDL-C is 3.6 mmol/L. The Aus CVD Risk Calculator gives a 5-year risk of 8%.^[6]

Step 1 — Should he be assessed, and with what?

Discussion:

• Yes. The 2023 Australian guideline recommends CVD risk assessment in all people aged 45–79 years without known CVD (from 35 years with diabetes and from 30 years for First Nations people).^[6]
• The guideline uses the Aus CVD Risk Calculator, based on an equation from a large New Zealand cohort study, customised and recalibrated for the Australian population; it replaces the Framingham-based approach of the 2012 guideline.^[6]

Step 2 — What does 8% mean?

• A 5-year risk of 5% to <10% is intermediate (low is <5%; high is ≥10%).^[6]
• BP-lowering and lipid-modifying pharmacotherapies should be considered for intermediate-risk individuals (and prescribed for high-risk individuals), unless contraindicated or clinically inappropriate.^[6]
• The figure is a 5-year risk, so it cannot be read against the 10-year thresholds of ESC or ACC/AHA guidelines.^[6][2][4]

Step 3 — Refine the estimate

• The guideline lists reclassification factors that may be applied to recategorise calculated risk, particularly close to a risk threshold: Indigenous status/ethnicity, eGFR, urine albumin to creatinine ratio, severe mental illness, CAC score and family history of premature CVD.^[6]
• His father's myocardial infarction at 50 is premature by the ESC/EAS 2025 Box 1 definition (men <55 years) and the ACC/AHA 2026 Table 13 definition (onset <55 years in a male parent or sibling).^[2][4]
• After discussion, a CAC scan is done: the score is 150 Agatston units, which ACC/AHA 2026 categorises as moderate (100–299).^[4]

Step 4 — How other guidelines would read his CAC

• ESC/EAS 2025: an increased CAC score by CT should be considered as a risk modifier in individuals at moderate risk or around treatment decision thresholds to improve risk classification (Class IIa, Level B).^[2]
• ACC/AHA 2026 (Section 4.2.7, men ≥40 or women ≥45 years): with a CAC score of ≥100 to 299 AU or ≥75th standardised percentile, LLT with statin therapy considered first line is recommended to achieve a ≥50% reduction in LDL-C and a goal LDL-C <70 mg/dL (1.8 mmol/L) and non-HDL-C <100 mg/dL (2.6 mmol/L) (COR 1, LOE B-R).^[4]
• ACC/AHA 2026 notes that observational studies have consistently shown that among adults with CAC ≥100 the incident ASCVD event rate is >7.5%, the PCE threshold above which statin therapy has been shown to be beneficial.^[4]

Step 5 — Decision and follow-up

• He and his GP agree to start a statin and to work on lifestyle; the Australian summary encourages healthy lifestyle modification, including smoking cessation, nutrition, physical activity and limiting alcohol, for all individuals.^[6]
• If his risk stays intermediate, the guideline says reassessment should be considered within two years; reassessment is not recommended for individuals at high risk.^[6]
• BP measurement and confirmation are covered in the hypertension diagnosis topic, and LDL-C goals and drug choice in the dyslipidaemia topic.

Step 6 — If he lived in Europe or the United States

• Europe: SCORE2 is recommended in apparently healthy people <70 years without established ASCVD, DM, CKD, genetic/rare lipid or BP disorders for estimation of 10-year fatal and non-fatal CVD risk (ESC/EAS 2025, Class I, Level B); under ESC 2021, in apparently healthy people without DM, CKD, genetic/rarer lipid or BP disorders aged 50–69 years, a SCORE2 of 5 to <10% is high risk and ≥10% is very high risk.^[2][1]
• United States: in adults aged 30 to 79 years without ASCVD or subclinical atherosclerosis and with an LDL-C of 70 to 189 mg/dL, the PREVENT-ASCVD equations should be used to estimate 10-year ASCVD risk, categorised as low (<3%), borderline (3% to <5%), intermediate (5% to <10%) or high (≥10%) (COR 1, LOE B-NR); his known CAC of 150 would instead bring in the ACC/AHA 2026 subclinical atherosclerosis rows above.^[4]

Key learning points

• Name the score, its time horizon and the guideline whose thresholds you are applying: Australian categories are 5-year risks; ESC and ACC/AHA categories are 10-year risks.^[6][2][4]
• In Australia (2023), reclassification factors, including CAC score, may be applied, particularly in individuals close to a risk threshold; ESC/EAS 2025 says an increased CAC score by CT should be considered as a risk modifier in individuals at moderate risk or around treatment decision thresholds to improve risk classification (Class IIa, Level B).^[6][2]
• In men ≥40 or women ≥45 years, a CAC of 100–299 AU carries a COR 1 ACC/AHA 2026 row (Section 4.2.7) for statin-based LLT with a goal of LDL-C <70 mg/dL.^[4]